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Restoring and SustainingHome: The Impact of HomeModifications on the Meaningof Home for Older PeopleBronwyn Tanner a , Cheryl Tilse b & Desleigh deJonge ca School of Rehabilitation Sciences, James CookUniversity, Townsville, Australiab School of Social Work and Applied Human Sciences,University of Queensland, Brisbane, Australiac School of Health and Rehabilitation Sciences,University of Queensland, Brisbane, Australia

Available online: 11 Oct 2008

To cite this article: Bronwyn Tanner, Cheryl Tilse & Desleigh de Jonge (2008):Restoring and Sustaining Home: The Impact of Home Modifications on the Meaning ofHome for Older People, Journal of Housing For the Elderly, 22:3, 195-215

To link to this article: http://dx.doi.org/10.1080/02763890802232048

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Restoring and Sustaining Home: The Impactof Home Modifications on the Meaning

of Home for Older People

Bronwyn TannerCheryl Tilse

Desleigh de Jonge

ABSTRACT. The importance of a supportive home environment to suc-cessful aging has been well-established in the literature, with home modifi-cations increasingly acknowledged as ways of removing barriers to functionand increasing independence for older people. Home modification literatureand practice primarily focus on the home environment as a physical space inwhich to perform tasks and on the impact of modification on competenciesand function. Home, however, is much more than a physical environment.Within a transactive framework, people and places are seen as engaged ina dynamic, reciprocal relationship through which home becomes a place ofsignificant personal meaning. Through a qualitative framework, this studyexamines the experience of older people living in the community who arerecipients of a home modification service. It explores the impact modifyingthe physical environment has on their experience of home as a place ofmeaning and provides insight into how home modifications can strengthen

Bronwyn Tanner, M.Phil., is Lecturer, School of Rehabilitation Sciences, JamesCook University, Townsville, Australia. Cheryl Tilse, PhD, is Senior Lecturerand Director of Postgraduate Research, School of Social Work and Applied Hu-man Sciences, University of Queensland, Brisbane, Australia. Desleigh DeJonge,M.Phil., is Lecturer, School of Health and Rehabilitation Sciences, University ofQueensland, Brisbane, Australia.

Supported by the School of Social Work and Applied Human Sciences, Uni-versity of Queensland, Brisbane, Australia.

Address correspondence to Bronwyn Tanner, School of Rehabilitation Sci-ences, James Cook University, Townsville, QLD 4811 Australia. (E-mail:Bronwyn.Tanner@jcu.edu.au.)

Journal of Housing for the Elderly, Vol. 22(3), 2008Available online at http://www.haworthpress.comC© 2008 by The Haworth Press. All rights reserved.

doi: 10.1080/02763890802232048 195

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the home as a place of personal and social meaning as well as improve safetyand comfort for the older person at home.

KEYWORDS. Meaning of home, home modification, ageing-in-place

INTRODUCTION

Although there has been increased recognition in the importance ofthe home environment to the health, well-being, and independence ofolder people (Australian Bureau of Statistics, 2005; Australian Instituteof Health and Welfare, 2003), it is only in the past 2 decades that researchon older people’s housing has shifted in focus from purposefully builthousing and institutional settings to existing housing and communityenvironments (Lanspery & Hyde, 1997; Powell Lawton, 1985; Pynoos,Cohen, Davis, & Bernhardt, 1987).

Several factors have driven this shift into focus. There has been a grow-ing awareness that existing policy frameworks in aged care are insufficientin responding to the future increasing size of the older population (Gray,2001) along with a recognition of the cost-effectiveness of policies thatassist older people in remaining in their communities rather than mov-ing to more specialized institutionalized environments (Andrews, 2002;Heumann & Boldy, 1993; Powell Lawton, 1985). The influence of thesocial construction model of disability, which has shifted the locus of limi-tation and impairment away from the individual and toward the recognitionthat the environment (Bricknell, 2003; Steinfeld & Danford, 1999; WHO,2001; Zola, 1997), has contributed to an increasing understanding of theimportance of changing environments to assist people in remaining in afamiliar home and community as they age (Faulkner & Bennett, 2002).Finally, there has been recognition of the need for changes in attitudes,policies, and practices so that the economic and social contributions ofolder people are supported and “people everywhere are able to age withsecurity and dignity and continue to participate in their societies as citi-zens with full rights” (Australian Institute of Health and Welfare, 2003,p. 275).

Generally, housing stock worldwide has not been designed or con-structed to accommodate the needs of older people in terms of accessi-bility, safety, independence, and location (Holm, Rogers, & Stone, 1998).In Australia, many older people live in housing built many years ago anddesigned with features that can become safety hazards and barriers to

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independence as occupants age (Bridge, Parsons, Quine, & Kendig, 2002;Faulkner & Bennett, 2002). Home modifications that adapt the physicalfeatures of the home to support independence are increasingly recognizedas an appropriate policy and practice response (Fange & Iwarsson, 2005;Pynoos, 1993b). Home modifications are defined as conversions or adap-tations to the permanent physical features of the home environment toreduce the demands from the physical environment to make tasks easier,reduce accidents, and support independent living (Fange & Iwarsson, 2005;Pynoos, 1993).

Within the home modification literature, only a small number of studieshave investigated the effectiveness of home modifications. In many studies,the term “environmental intervention” refers to the physical modification ofthe home environment (Connell, Sanford, Long, Archea, & Turner, 1993)and to a combination of interventions, including assistive technology orequipment, environmental simplification, and education, performed by atherapist (Cumming et al., 1999; Gitlin, Corcoran, Winter, Boyce, & Hauck,2001; Giltin, Swenson Miller, & Boyce, 1999; Mann, Ottenbacher, Fraas,Tomita, & Granger, 1999; Trickey, Maltais, Gosselin, & Robitaille, 1993).

Research findings suggest that such environmental intervention has less-ened the difficulty and dependence in performing household tasks for peo-ple with a mobility impairment (Connell, Sanford, Long, Archea, & Turner,1993), improved the functional performance in areas of self care and instru-mental activities of daily living for the frail elderly, people with dementia,and those with mild functional impairment (Giltin et al., 1999; Mann et al.,1999; Stark, 2004; Trickey et al., 1993), and reduced the need for and theeffectiveness of caregivers (Gitlin et al., 2001; Lanspery, Callahan, Miller,& Hyde, 1997).

Task performance, in terms of parameters such as independence, safety,and quality, has become a key way that researchers in the home modifica-tions field have operationalized the concept of “person–environment fit”(Faletti, 1984; Steinfeld & Danford, 1999). In particular, there has been afocus on the use of assessment of activities of daily living and instrumen-tal activities of daily living as indicators of functional independence and,therefore, person–environment fit.

The desire of older people to remain at home while they age, however,is not solely related to task and function. It has much to do with subjectivefeelings about what home means to them (Oswald & Wahl, 2005; Sherman& Dacher, 2005). In environmental psychology, it has been proposed thatit is the relationship between a person and their dwelling that defines theessence of what “home” is (Dovey, 1985) and the impact of home on health

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and well-being is increasingly being recognized (Rowles & Chaudhury,2005).

There is increasing interest in exploring the links between older peopleand their home environments and the effect that disruption to the home hason well-being (Rowles & Chaudhury, 2005). Recent studies have shownthat older people spend more time in their homes and it is because of thisthe home takes on greater significance and becomes the spatial focus ofthe older person’s life and a way of preserving independence in the faceof possible decreasing function and increasing disability (Oswald & Wahl,2005; Sixsmith & Sixsmith, 1991). Older people order and manipulatethe home environment to both accommodate increasing limitations and berepresentative of themselves and their lives, with memories and home ofteninextricably linked (Rubinstein, 1989; Sherman & Dacher, 2005; Sixsmith& Sixsmith, 1991). Older people have a clear relationship between thephysical environment they inhabit and their feelings of belonging are notnecessarily tied to legal ownership or long occupation (Davison, Kendig,Stephens, & Merrill, 1993).

Although this subjective relationship of person and home is acknowl-edged as central to the experience of older people remaining at home,there has been little investigation of how home modifications affect thisrelationship. The small amount of research on this topic that does existraises questions about the potential of modifications to both support anddetract from this relationship (Heywood, 2004, 2005).

The study reported in this article investigated the experience of olderpeople who received home modifications and the impact changes to thephysical home environment had on their experience of home. The keyresearch question was: What is the impact of home modification on theexperience and meaning of home to older people living in the community?

CONCEPTUAL FRAMEWORK

The research draws its conceptual framework from the literature aboutthe meaning of home and the transactional framework of understandingperson–environment relationships. Within a transactive perspective, peopleand their environments are integrated and mutually defining. Temporalqualities are intrinsic to person–environment relationships and transactiveprocesses between the person and their environment occur at the level ofaction and at the level of meaning (Altman, Brown, Staples, & Werner,1992; Steinfeld & Danford, 1999; Werner, Altman, & Oxley, 1985).

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The home environment is conceptualized as having 3 primary modesof experience (Lund & Nygard, 2004; Oswald & Wahl, 2005; Sixsmith,1986; Smith, 1994). These are:

� The physical home—consisting of the concrete raw materials and thedesign and layout of the dwelling. It refers to the space that can bemeasured and is shaped by function, culture and history (Sixsmith,1986; Steward, 2000).

� The social home—encompassing relationships with significant others,such as a spouse or family member, who may often inhabit the samephysical environment and also includes those who may enter the homeon occasion or exert an influence from outside the home such asrelatives, neighbors, friends, and community networks (Dunn, HaneyMcClain, & Youngstrom, 1998; Rubinstein, 1989; Sixsmith, 1986).

� The personal home—being a place of self-expression, identity, andpersonal control; a central reference point in a person’s life encapsu-lating feelings of familiarity, security, and belonging (Depres, 1991;Dovey, 1985; Sixsmith, 1986).

Home, as a physical, social, and personal experience, occurs within atemporal framework, reflecting the dynamic and changing nature of themeaning of home for individuals over time. Peoples’ relationships withtheir homes have histories, futures, recurrences, and rhythms that affecttheir current experience and meaning (Dovey, 1985; Werner et al., 1985).

METHOD

A qualitative methodology reflects the aim to deepen understandingsof the subjective world of older people in relation to their home and theimpact home modifications have on this world.

Sample

Participants were purposefully sampled to provide as much diversity aspossible within the target group. The sample was selected from a popula-tion of older people (65 years and over) currently residing in public housingin a metropolitan area who had been in receipt of a home modification totheir current accommodation within the previous 3 to 6 months. The re-searcher had access to the files as an employee of the organization. Current

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clients of the researcher were excluded from the study to ensure that theresearch/service delivery roles were clear with participants. Voluntary in-formed consent was gained from all participants and ethical approval wasobtained from both the University of Queensland and the relevant govern-ment department. No identifying data has been included in any materialpresented from this research and the confidentiality of all participants hasbeen maintained.

Selecting from public housing tenants provided a sample with simi-larities in income, security, and type of housing tenure and experienceof home modification service delivery. Although most older Australiansare homeowners rather than public housing tenants, and the literature hasidentified that older people on low incomes in private rental are most atrisk, public housing, as key provider of accommodation for older peopleon low incomes, has a well-established free home modification programthat is currently unavailable to the same extent in the private housing sec-tor. Public housing also provides an opportunity to investigate consumers’perspectives in an environment where key recognized “barriers” to homemodifications up take, such as cost, access to services, and lack of informedservice providers, have generally been overcome.

Initial data were collected using occupational therapy reports that pro-vided demographic data, a profile of participants’ medical issues and func-tional status, and a list of recommended modifications to their home envi-ronments. Twelve participants who had received home modification in theprevious 3 to 6 months were chosen from occupational therapy reports inpublic housing files to include a range of ages, living arrangement, level ofdisability, and gender, housing types, and home modifications. The purpo-sive sample included 4 men and 8 women, with an age range of 60 to 90years, and a mixture of people living alone (n = 5), living with a partner(n = 5), or with other family (n = 2). Partners and carers were includedin the interviews as relevant or requested by the participant. Participantslived in public housing that ranged from a small one bedroom unit (n =2) to one (n = 1), two (n = 1), three (n = 8), and four bedroom (n = 1)houses.

Data Collection

Semi-structured, in-depth interviewing was the primary method of datacollection. The data collection occurred over a period of 12 months, witheach participant being interviewed once. The interview guide that was usedincorporated predetermined questions but also allowed for a less structured

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conversation or narrative to occur. The interviews were between 1 and 2hours in duration and were audiotaped, with the exception of one partic-ipant who declined to be recorded. In this case, notes were made duringthe interview of participant’s responses and extensive notes made imme-diately after the interview recorded as much detail and exact phrasing aspossible.

Data Analysis

Audiotapes of the interviews were transcribed verbatim into written dataincorporating observed responses and other researcher notes and memos.N-VIVO software was used to assist in the management of the data andthematic analysis of the transcripts (QSR, Melbourne, Australia). Themajor themes in the interview data were identified using both indigenouscodes (those generated by participants) and references to the conceptualframework of this study. Initial codes were grouped into broader categoriesor themes according to their “internal homogeneity,” the extent to which thedata in a certain category held together, and their “external heterogeneity”(the extent to which differences among categories were bold and clear)(Patton, 2002, p. 465). A second independent coder was used to confirmcategories. Care was also taken to note participants who did not fit withinthe common themes and those who had different experiences to report.

FINDINGS

The major themes identified in the analysis of the data related first towhat participants said about their experience and the meaning of home andsecond to how home modifications affected this meaning. The analysisalso identified several other themes related to service design and deliverythat had the potential to affect the experience and meaning of home forolder people.

The Meaning of Home

All the participants of this study spoke about home as a place of signif-icant personal and social meaning.

The Personal Home: Making Meaning Through Action

One of the key findings of this study was that acting on the physicalenvironment was the primary way in which participants “made” a house

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into a home. This has direct implications for home modification practice.Participants spoke of gardens they had created, improvements they hadperformed, and furnishings, decorations, and personal objects they hadinstalled, all of which made their dwelling place a home to them. Controlover the home environment was also a theme that emerged related to this.

We put extra cupboards up, varnished the floors, put curtains andblinds up . . . just made it home. (Gregory, aged 75 years)

Personalizing their houses with significant objects was also a commoncharacteristic with participants in creating “home.” Objects on displaywere often of great personal significance with even small items, such asmatches, representing life events, personal history, and meaning. Photosin particular held great personal meaning and were seen as an extension ofthe relationship with the people they represented.

That picture up there, (indicating a black and white photo of a manand woman), that was taken the day war was declared. See that onewith the air force man? On the other side there’s a photo of a soldierand a girl? Well that’s G and I. I was 17, and he was 21. And that wasthe day war was declared. It was an open day at (E) camp Frasier’spaddock. At 5-o’clock in the afternoon, Churchill, it came over theloud speaker that war had been declared. . . . All the paintings you seearound, our families have done those. (Clare, aged 86 years)

The Social Home: Roles, Relationships and Networks

The meaning of home as a place to strengthen and secure importantrelationships was a theme that emerged strongly from this study. For someparticipants, social relationships were of more importance and high valuethan other aspects of home such as comfort, ease of access, and function-ality. Relationships that extend outside of the home were as highly valuedas those within the home. Existing social networks contributed strongly tothe essence of what home meant and to the individuals’ sense of identity.

This was particularly evident for one participant who reported greatdifficulty in managing the steps and bathroom of her current home. Becauseminor modifications had given her little functional improvement, she wasoffered new fully accessible accommodation less than 1 kilometer awayfrom her current home. One of the main reasons she gave for declining thismove was that she would lose her role as an informal “bus stop guardian.”

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For many years, she monitored children getting on and off the bus becausethe school bus stopped outside her house, with many of them waiting inher yard in the morning and afternoon under her protective eye. She valuedthis role higher than the need for ease of access to her house or bathroom.

I enjoy it here. The fact . . . [that] I have about 8 or 10 kids come of amorning now that school’s started. They wait here; if it’s raining, theywait on the veranda and otherwise they’ll wait in the yard and go outwhen the bus comes for the children . . . and I like to be able to makesure they’re on the bus safe. Some of them get off here in the afternoonand the rest will get off in front of their place or another stop furtherdown. But they all like to get on here. . . . By them being here thebus comes along up the road here, they walk across to catch it and Iknow they’re safe. . . . It makes you feel you’re doing something eventhough I’m not really doing anything . . . to most of the neighborhoodchildren I’m “Nanna.” It doesn’t matter whether they are related ornot. I’m Nanna. Even the 18- and 19-year-olds . . . still refer to me asNanna. I’ve got a very large family! (Betty, aged 66 years)

The Physical Home—Space and Comfort

Related to the importance of the social experience of home, many par-ticipants emphasized having physical space. For many of the people in-terviewed, space was an important factor in their enjoyment of homebecause they identified the need to have space for family to come and stay.Space was also identified as important for keeping pets. Maintaining acomfortable physical environment, particularly by managing the discom-fort of heat and having pleasing aesthetics, was also an issue for manyparticipants.

The Future Home—Out in a Wooden Box

The desire of participants to remain in their current home and nothave to move was strongly evidenced in the findings. This study sup-ports the often expressed assumption that most people wish to remain intheir home as they age, preferably until they die or at least are not able tomanage for themselves any longer.

As for this place, the only way they’ll get me out of here is to takeme out in a wooden box. (Jean, aged 66 years)

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Impact of Home Modifications on the Meaning of Home

Restoring Home as a Place of Security Safety and Comfort

In examining the impact of modifying the physical environment ofthe home, the findings show that reducing the demand of the environmentthrough modifications strengthens the personal home as a place of security,safety, comfort, and control rather than one of risk, dependence, struggle,or even imprisonment. Participants of the study spoke of how modificationshave increased independence, safety, and comfort in performing daily tasks.

It’s great, just great. They put grab rails all around. . . . [It’s] safer. . . [and] it’s more convenient too. It’s much more comfortable.(Colin, aged 77 years)

Independence, Identity, and Impact on Carers

Participants reported that modifications increased their independence,allowing for the maintenance of habitual personal routines. Independenceafforded by home modifications also resulted in greater feelings of con-trol and self-efficacy. Some participants no longer had to rely on others(community services or spouses, in particular) to assist in personal care orto provide meals. In theses cases, modifications reinforce the control anindividual has over routines, daily activities, and others’ access to them(privacy). Home, as a place of personal control, mastery, and self-efficacy,is reinforced.

I’ve got more confidence and I don’t have to depend on somebody tobe here in case I fall. It’s made me totally independent now. (Jean,aged 66 years)

In reducing reliance on carers, who are often spouses or family members,there was often a reported alteration in the dynamic of the relationship.One participant reported feeling less “cosseted” by his partner and othersreported that their spouse was less tied to the house and more able to engagein preferred activities by no longer having to be present to assist them.

To be able to get around like that without having to be cosseted . . . it’svery important. Luckily I’ve got a younger wife who [is] very goodto me. She looks after me anyway, but it’s much better if I can do

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some things for myself. It’s better for my self-esteem and also for herbenefit as well. She’s got a bad back as well and so it doesn’t helpmatters. (Colin, aged 77 years)

One carer reported a dramatic change in the quality of life for both herfather (for whom she cares) and herself as a result of having a water liftinstalled.

[It’s been] excellent! We’ve been dirty stop outs! We’ve been outnearly every day. It’s improved the quality of life. . . . Oh yeah wewere just pulling our hair out—so locked up! I know what it’s liketo be in prison but now we’ve just been going everywhere. Oh yeah,we’re very very happy. We’ve never been the happiest as when wesaw it. . . . We thought “Oh, fantastic.” (Rhonda, daughter and carerfor Ray, aged 72 years)

Modifications also supported the continuation of existing social net-works and important social roles by facilitating the ability to remain inplace and keep those connections.

Impact on the Future

The impact of home modifications on participants’ view of their futurepresented a variety of responses that appeared unrelated to gender or livingarrangements. For some, having modifications completed made them feelthey were well prepared for the future and reduced the likelihood of havingto move. Others, however, reported a strong determination to remain livingin their home as long as possible irrespective of whether the modificationshad been completed.

Impact of Modification Design to Accessible Standards

Although the findings of this study clearly show that improved function,comfort, and ease of access around the physical home were key outcomesfor participants, there were several points of interest identified around theimpact of the use of design standards as the basis of home modificationdesign. This particularly related to where major modifications were doneto the bathroom or entrances to a dwelling. These major modificationswere usually based on the Australian Standards for Access and MobilityAS 1428 (Standards Australia 2001), a public access standard for designbased on wheelchair accessibility. None of the participants in this study

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who had major bathroom modifications used a wheelchair inside theirhome and most reported that they did not expect the level of accessibilityprovided.

For two participants, this was well received, but there was less satis-faction with the design for others because some were concerned about theimplications of designing for wheelchair accessibility:

When the ramp was finished, this workman with a really loud voicecalled out “this is now a disability house!” really loudly—the wholestreet would have heard. (Olive, aged 76 years)

There was also a sense of frustration at trying to get design features thatwere considered to be to a particular “disability” standard changed:

What I did find and that I was a bit cranky about, the clothesline wasabout the right height to decapitate me when I walked out. It was theright height for a wheelchair. I asked them to come and lift it and theysaid get knotted and I had to do it myself. (George, aged 64 years)

Loss of Home—Negative Impacts on the Experienceand Meaning of Home

There were few reported negative outcomes as a result of the modifi-cations. Two participants, while reporting overall positive outcomes, didreport minor negative outcomes related to the design of a vanity unit anda poor outcome with a piece of assistive equipment. There was, however,one participant who was predominately negative about her modifications.As this was contrary to all other participants, this case was examined indetail because it provides insight into the elements that may precipitatehome modifications having negative outcomes for older people and, as aresult, negatively impact the experience and meaning of home.

The participant was a widow who lived alone in a house she had occupiedfor over 40 years. She had received modifications, many to AS 1428 designstandards, to the entrance and external paths to the carport, bathroom, andkitchen. During the interview, she revealed that she did not initiate therequest for modifications nor did she expect the extent of modification thatoccurred. She spoke frequently about the loss of her “old’ home and thedisruption to routine and habits due to the modification design. The oneaspect of the modifications that she was happy about (the small ramp atthe front of the property) she stated several times during the interview was

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“her idea.” This is perhaps the one change she felt was in her control andfor which she felt a sense of personal ownership.

This case highlights how changes to the physical home environmentthat are intended to improve function and accessibility can negativelyeffect the personal meaning of home. Issues raised by this participantinclude the level of participation and control over what changes are madeto the home environment and the importance of ensuring that proposedchanges are suited to individual need.

Other participants also reported issues of participation and control. Ingeneral, the majority of participants reported satisfaction with the serviceprovided and this was particularly the case for those who had positiveinteractions with service providers and those who perceived that theywere included in the decision-making process. In instances where par-ticipation or input was not perceived to be adequate, participants waiteduntil the work was to commence and then exerted control over the finalwork either by rejecting the proposed change or getting the contractorsto modify the work to their specifications. Other factors that negativelyimpacted the satisfaction of services users included the difficulty in gettinginformation about the service, the amount of time taken from referral tocompletion, and the lack of follow up and quality assurance of completedwork.

DISCUSSION

The central question driving this study concerned the impact that homemodifications have on the experienced meaning of home by older peopleliving in the community. The experiences of participants in this studydemonstrate that home modifications positively effect the meaning ofhome by restoring or strengthening home as a place of security, safety,and comfort by decreasing the demand of the environment and supportingthe continuation of habitual personal routines or rituals through whichpeople are linked to their home and by which identity, self-esteem, andcontrol are reinforced.

The literature proposes that the performance of daily routine tasks isimportant processes “linking or anchoring a person to a home place”(Pastalan & Barnes, 1999, p. 82). The performance of these daily tasksor rituals contributes to the creation of “insideness,” a sense of famil-iarity that is “rooted in bodily routines” that are taken for granted andeventually unselfconsciousness. As a consequence, home becomes a place

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of relaxation because of the stability of routine behavior and experience(Dovey, 1985, p. 38). These routines also contribute to a sense of comfort,control, and identity because, as highly individualized activities, “they givemeaning to individuals in terms of who they are, what they are, what theydo and why they do it” (Pastalan & Barnes, 1999, p. 83). Rowles (2000)describes the “choreography of Being-in-Place” as a melding of “habitualphysical routines, habitual social routines and a sense of autobiographicalinsideness” (p. 59S) into a complex system of “inextricably linked ac-tions, relationships and environmental meanings in a state of homeostasis”(p. 59S). When these rituals are unable to be performed, this homeosta-sis is disrupted and there is a diminution of self and a loss of identity,self-esteem, and relationship to place and community (Pastalan & Barnes,1999; Rowles, 2000). Home modifications, therefore, assist in sustaininga sense of place and a sense of self by supporting the performance of dailyrituals.

This study also showed that home modifications positively impactedsocial relationships and networks associated with home. Existing stud-ies on the outcomes of home modifications have reported positive effectson caregivers from environmental changes (Gitlin et al., 2001; Heywood,2004; Lanspery & Hyde, 1997) and this study supports these findings.In this study, carers reported a reduction in the worry or strain of car-ing and an improvement in their own quality of life as outcomes of homemodifications. Home modifications, therefore, positively affected “the typeand quality of relationships and the emotional environment they afford”(Smith, 1994, p. 33), identified by Smith as a significant aspect of the socialdimension of home. The importance of maintaining valued roles was anadditional theme that emerged from the findings. Home modifications sup-ported the maintenance of roles within the home and the wider communityby facilitating remaining in place.

Although the impact of home modifications was positive for the majorityof participants, this study does demonstrate the potential for modificationsto detract from the meaning and experience of home. The study highlightedseveral key elements that have the potential to contribute to the loss of asense of home.

First, the experience of home can be diminished when the physical as-pects of accessibility and functionality are emphasized and the personaland social meanings of home held by the home dweller are neglected ordisregarded. Closely associated with this is the level of participation bythe home dweller in the decision-making processes around the proposedmodifications. Hawkins and Stewart (2002) identify that there can be “a

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mismatch between the adaptations considered and the symbolic meaningof the home environment to the disabled person” (p. 83) when profession-als focus on the functional limitations of the clients in isolation to theirexperience within a social or family dynamic. This type of conflict hasalso been identified as occurring between caregivers and goals that areestablished by health and human service professionals (Gitlin, Corcoran,& Leinmiller-Eckhardt, 1995). Findings from this study show that partici-pants who experienced a clash of values when they felt that their prioritieswere not understood or considered were reluctant to seek further assistancefrom the service provider. A consequence of this reluctance could be thatthe individual is placed at risk, particularly if their function deterioratesfurther.

The issue of participation and control over the modification process isone that has been identified in the literature as a key area of concern. Astudy into home adaptations in England and Wales found that wastefuladaptations (those resulting in poor outcomes because of a misdiagnosisof need) were “most often the result of limiting assessment to functionalphysical issues and leaving out psychological factors such as the needfor dignity and sense of control. They were also typified by failure toheed the views of disabled people and families concerned” (Heywood,2004, p. 130). Nocon (1997) stresses the importance of consulting withprofessional staff and communicating with and listening to people with adisability when important decisions are being made about their housing.Ensuring that participants are actively engaged in the decision-makingprocess of the intervention reinforces the meaning of home as a primaryterritory with a perceived degree of personal control (Oswald & Wahl,2005; Smith, 1994). Ensuring that the priorities of older people are heardand that a participatory approach to assessment and decision making isundertaken are important requirements of a home modification service andare particularly relevant to the approach taken by the occupational therapistinvolved in the service. In this study, participants were more likely to besatisfied with the overall outcome of the modifications if they perceivedthat they had an active role in the decision-making process regarding thepotential changes to their home. It also appears that the experience ofhome can be undermined when modification design is driven primarily byaccessibility codes and standards for “typical” situations rather than by thespecific needs and requests of the individual home dweller.

There has been a continued debate in the literature over the use of“design standards” as the basis of home modification design (Danford &Steinfeld, 1999; Pynoos & Regnier, 1997; Pynoos, Sanford, & Rosenfelt,

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2002; Steinfeld & Shea, 1993). The debate centers on the use of standardsor codes developed for public access and set out to provide the greatestaccess for the greatest number of people.

Although logical from a public administrative resource allocation andmanagement perspective, applying this approach to home modificationdesign is problematic because the meaning of home as a private, person-alized space is undermined. Accessibility codes are typically designed todetermine minimal legal guidelines and have little to do with the needs,aspirations, desires, and uniqueness of a particular individual (Danford& Steinfeld, 1999). The current public access standards are not based onresearch for older people. Assuming that designing for wheelchair use willbe suitable or appropriate for the older person with a range of mobilityneeds is an untested hypothesis that has not been evidenced in research.In fact, research in the United States has proven that some modificationsto the existing accessible standards “may promote more disability amongolder adults than it ameliorates” (Pynoos et al., 2002, p. 16).

Implications and Recommendations

As an exploratory study, it is not proposed that any generalization tothe broader population can occur. It is also acknowledged that the par-ticipants in this study are from a particular section of the population ofolder people (i.e. those living in public housing). However, in the light ofthe understandings gained from this study, the following implications aredrawn.

Implications for Occupational Therapy Practice

Occupational therapists are increasingly being recognized as playing animportant role in home modification service process and delivery, partic-ularly in the areas of assessment, follow up, and evaluation of completedwork (Pynoos, Nishita, & Perelman, 2003; Pynoos et al., 2002). The oc-cupational therapist also has the responsibility of determining which mod-ifications will “fit the specific needs and capabilities of the individual”(Pynoos et al., 2003, p. 113). The importance of participatory consultationand decision making rests strongly with the occupational therapist becausethey are often the first face-to-face contact experienced by service recip-ients. Further investigation into the professional frame of reference andassociated model of practice used by occupational therapists working inthis area is recommended to determine whether participatory and collabo-rative decision making is occurring and whether the occupational therapy

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intervention supports the unique relationship between a person and theirhome.

Implications for Service Design and Delivery

Based on the findings of this study and related literature, there is a needfor better information about and promotion of existing home modificationsservices and the benefits of home modification to older people in thecommunity. Further investigation is recommended to determine whethera lack of regular evaluation and continuous improvement is also presentwithin other existing home modifications services. A consequence of poorfeedback and evaluation is a paucity of information about the effectivenessof home modifications to guide in the development of best practice modelsof service delivery, which, as this study highlights, need to be cognizant ofthe subjective meaning of home in design and delivery home modificationservices.

CONCLUSIONS

Although small in scale, the strength of this study is that it seeks todeepen understandings of the subjective world of older people in relationto their home and the changes that home modifications have brought to thisworld of meaning. This study highlights the benefits of home modificationsto the experience of older people beyond the observable function andindependence paradigm of many of the empirical studies in this area.

This study shows that home modifications have the potential to enhancethe experience of home as a place of significant and unique personal andsocial meaning for older people. Care needs to be taken, however, to ensurean awareness of the meaning of home to older people is embedded in thepolicy and practices surrounding the provision of home modifications.

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